Palmetto GBA
^ Back to Top
Close Window [x]
  • J11 HHH
  • J11 Part A
  • J11 Part B
  • NSC
  • Railroad Beneficiaries
  • Railroad Providers

Bookmark E-mail Print Digg It! Tweet FB Like Show/Hide Google+ line
Standard Font Serif Font Decrease Font Size Increase Font Size

Railroad Medicare
Guidelines for Anticoagulation Therapy Monitoring

CPT code 99211 represents the lowest level office visit and may be reported 'incident to' for a patient encounter with the physician’s licensed auxiliary personnel. To report CPT code 99211 service in addition to a venipuncture for drug treatment monitoring such as anticoagulation therapy or for a maintenance injection service, the licensed personnel must perform a face-to-face service and document at least one of the following reasonable and necessary criteria:

  • A minimal presenting problem/symptom
  • A relevant and necessary exchange of information between licensed personnel and the patient

If the service does not meet the above criteria, the work for the service is included in the initial E/M and may not be reported separately with CPT code 99211 service. 

Patient education/counseling, an important part of maintenance therapy, should occur and be billed during the initial treatment plan and E/M service. Palmetto GBA does not consider repetitive 'boiler plate' documentation or repeated education/counseling after the initial patient visit as reasonable and necessary.

Example One
A patient reports to a laboratory draw site. The specimen is drawn, tested and anticoagulation results are sent to the physician’s office. The review of the test results is included in the E/M service when the order for the blood draw was written. The physician may not report CPT code 99211 service for his or his auxiliary staff’s time for reimbursement.

Example Two
A patient reports to the clinic for a routine venipuncture/injection. During the venipuncture/injection, the patient reports a problem or the staff identifies a problem. The patient is seen by the physician to further address the problem. The physician documents the exam and adjusts the treatment plan as needed. An E/M service may be billed for the physician exam and assessment. Physicians who exceed their peers with high frequency of CPT code 99211 in addition to a venipuncture or injection service may be targeted for review and RAC referral.



last updated on 07/01/2013
ver 1.0.51